ICD-10: Painful To Implement, Painful To Delay

Congress is on the verge of delaying healthcare's new diagnosis code system for another year -- a relief to doctors, but a pain for CIOs.

If the implementation of ICD-10 diagnosis codes is delayed by an act of Congress, as seems likely, doctors may be spared a headache -- but healthcare CIOs will gain one.

Easy-to-Mock ICD-10 Diagnosis Codes

(Click image for larger view and slideshow.)

The Centers for Medicare and Medicaid had set forth a firm October 1 deadline for the implementation of a new and vastly expanded system of diagnosis and insurance billing codes, a transition that has been in the works since the 1990s and had been pushed back repeatedly. On Thursday, the US House of Representatives passed a "doc fix" bill including a one-year extension of the deadline. The ICD-10 provision is one paragraph in a larger bill mostly focused on postponing cuts in Medicare reimbursement to doctors that would otherwise be required under the Sustainable Growth Rate formula, which was part of a cost containment act passed in 1997. The ICD-10 provision seems to have been thrown in as a consolation prize for the physician's lobby, after efforts to permanently repeal the SGR formula fizzled, and this latest compromise won the backing of both Speaker of the House John Boehner and Senate Majority Leader Harry Reid. The Senate is scheduled to vote Monday night. [Update: the bill passed the Senate 64-35.]

The American Medical Association decried this compromise, but not out of any love for ICD-10, which the organization predicts will be extremely costly for physicians, meaning that "the AMA continues to work to stop its implementation altogether."

The AMA estimates the cost of switching to ICD-10 at as much as $8 million for a large physician practice and more than $225,000 for a smaller one. AMA's objection to the doc fix bill is that another temporary delay to SGR is not good enough. "There was bipartisan, bicameral support for reform this year, yet too many in Congress lacked the courage and wherewithal to permanently fix Medicare to improve care for patients and provide greater certainty for physician practices. Congressional leadership had to resort to trickery to pass an SGR patch that was opposed by physicians," according to a statement from AMA President Ardis Dee Hoven, MD.

As a practical matter, doctors are still likely to prefer a delay to both SGR and ICD-10 implementation to no relief at all. Doctors worry that, with about 64,000 very specific ICD-10 codes, they will have a much harder time recording the right data to get their claims paid by CMS and by insurers.

"There's going to be complete confusion if you don't do everything right in the billing process and fill it out the right way," one emergency medicine doctor told me. "This is another way of not paying you -- that's the cynical view." I'm withholding his name because the quotes he gave me on the record were much so less colorful. If a doctor records the diagnosis code of "congestive heart failure" rather than one of the 29 more specific codes for types of congestive heart failure included in ICD-10, "then they just don't reimburse you for the visit or the care of the patient," he said. "People could wind up going bankrupt in medicine, because they're not getting reimbursed for anything because it's so complex."

As an emergency department specialist who works at several different hospitals, he also can't count on the EHR systems to save him by simplifying the process of looking up codes. Because the hospitals all use different EHRs, he expects that he really is going to have to memorize at least the most common ICD-10 codes if he wants them to be captured properly for his bill (which is separate from the hospital's bill). This is one case where the priorities of the institution are different from those of the physicians.

Rob Tennant, senior policy adviser for the Medical Group Management Association, said the government still hasn't invested in enough testing and preparation for the transition to ICD-10 and it shouldn't be rushed. "The proponents tend to be people who aren't responsible for the financial costs of this transition." Doctors in private practice and group practices are the ones most likely to "pay out of pocket," he said.

Also, with the rocky launch of HealthCare.gov still a recent memory, lawmakers are sympathetic to worries about the implementation of another big government-led technology project, Tennant said.

Meanwhile, hospitals and the healthcare IT community are decrying the cost of delay. The legislative initiative is "a real disappointment to CHIME members, who have long prepared for ICD-10, installing new systems, training staff and otherwise making the needed changes that will affect patient care," Russell P. Branzell, President and CEO of the College of Healthcare Information Executives (CHIME) said in a written statement.

CHIME also participated in a joint statement of opposition from the Coalition for ICD-10, which is made up mostly of technology-oriented groups, including the American Medical Informatics Association and the American Health Information Management Association, which represents coders and other professionals who collect and analyze healthcare information. The coalition also includes the American Hospital Association, the BlueCross BlueShield Association, and WellPoint.

Dan Haley, Athenahealth's vice president of government affairs, said it's true many doctors are anxious about the change but that's because their technology vendors have let them down, whereas "we did the work to get our doctors ready." For the government to insist that the industry and its technology vendors meet a given standard, and then back off, is a bit like parents telling their children "no dessert unless you eat your dinner -- and then you don't eat your dinner, but you still get dessert."

Many healthcare IT organizations took it for granted that the government would punt the deadline yet again, and it looks like they were right, Haley said. "Anecdotally, what we've heard is that the doctors groups, in exachange for not making too much noise about SGR, will get the ICD-10 delay. I'd say there's a 90 percent or better chance this whole thing passes. It's pretty rare you have bipartisan leadership in both chambers ramming something through."

American Health Information Management Association CEO Lynne Thomas Gordon acknowledged the political odds seemed to be stacked in favor of the bill's passage. "I'm holding out all hope. It would be such a shame" if the delay passes, she said, after all the work her members have done to gear up for the change.

The current coding scheme is "ancient, with no more room to upgrade codes" and fails to include categories for modern worries like bioterrorism or even to distinguish between a wound on the right side or the left side of the body, Gordon said. In the absence of precise codes, coders wind up fudging their records with approximate descriptions based on the code that is the closest match, she said. "We feel very strongly that ICD-10 is more granular, more specific."

A delay would also be harmful to more than 25,000 students currently studying to work as medical coders -- many of whom have been trained exclusively on ICD-10 under the understanding that it would be the exclusive standard by the time they graduated, Gordon said.

Cleveland Clinic CIO Martin Harris, an MD who has spent his career seeking better ways of analyzing health data, said the greater specificity in ICD-10 will translate into better tracking of how care is delivered and how it can be improved. "Used properly, there is no question we'd get a refinement around what we know about caring for patients clinically." On the other hand, he added, "To get to those refinements, there's a cost -- someone has to enter the data this way." His IT organization is trying to minimize the potential loss of physician productivity by designing EHR screens that make it easy to pick the most frequently used and appropriate codes, but exactly how that nets out remains to be seen.

Whatever the tradeoffs, delaying ICD-10 now will have its own negative consequences, Harris said. "It would be an enormous impact on the training programs we have set to take place over the next six months," for which teams of trainers and facilitators have already been assembled. "If we were to say 'stop' now, those teams have to go away, and then they would be reassembled," gearing up to do the same thing again next year. "That's where you'd see the expense. Starts and stops are never good for the budget."

With the legislation including the delay seemingly likely to pass, Harris said his staff "is scrambling right now," trying to figure out the best way to salvage the work in which it has invested. He is holding out some hope that it might be possible to negotiate some way that "those organizations that are ready to go could continue to move forward" and start submitting data in ICD-10 format, even if it would not be mandatory for those who are unprepared for the transition. Whether that's something payers would agree to he wasn't sure.

In a separate interview, AHIMA's Gordon suggested that was a nice thought, but probably impractical. "I would think that would be very difficult for the industry. All of your payers would have to support dual coding systems, which would be very onerous."

One way or another, it seems, someone is going to feel the pain.

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First it is excellent that it is going to being delayed. I am a critical care physician and have used many EMR

I have been involved when I was DOD healthcare implementing EMR and telemedicine

ICD 10 is generally a good product for its specificity and granularity. I am familar with the people who worked on SNOMED. In reality Snomed has been close to 20 years and althoug it has great specificity and exactly more in line with physicians thinking , it is cumbersome for physician to use and it is great for an healthcare dictionary for coding.

1. To make this right, this needs to be field tested by physicians in many organizations and study completed to see if it has any significant improvement in outcomes, qulaity of care, and improves productivity and efficiency.Goal is not to make physicians a documentation puppet but to give care to patient. Looking at the ICD 10 compared to ICD 9, ICD 10 is certainly will cause more physicians to be less productive. The reality is even with present EMR including EPIC and Cerner (has better coding database) most physicians do not use the EMR codes. Problems and diagnoses are not necessary updated. In reality most physicians free test codes. I suspect the of ICD 10 will be to free text more codes in their progress notes rather than wasting time with granularity that govt, healthcare informatics zealots, and the lobbyist who want this system. The bottom line if it impacts productivity do not expect that physicians will use this. I suspect in general that greater details may produce some more reimbursement but at the expense of multiple times to get right codes in. I suspect the reimbursements will decline for physicians overtime in spite of extensive more documentaton.

2. We should know what percent of the codes ICD 10 documentation improves reimbursement for physicians. I

3. Although ICD 9 to ICD 10 calculators will be helpful, it still is cumbersome mainly because you are going to have detail ingreater depth the diagnoses. You need severity, laterality, associated conditions, etc. This is onerous.

4. Many statements are being made how it will improve quality of care, outcomes, better data, better reimbursement. I take all these statements for granted and there is not much to support these claims.

5. Like a family practic doctor said,the laterality and other specificy in coding does not make much difference for healthcare insurances for reimbursement. There are going to be exceptions but I do not see the granualrity that has needed here .

6. ICD 10 would be ideal for one problem: Death certificates. IF Information in ICD 10 if it could be entered on death certificates will be a better tool to document events leading to a patients death and therefore a bettter comparison on outcomes on international level for various countries.

Re: Convert and Train You Entire Staff in 90 Mins for $1,788 Annually (Mapping and Dual Coding) in Seconds

The complete lack of integration within EHRs is crazy. At a time when most other industries won't look at a system unless it's open and integrated, healthcare providers don't have that option for one of the biggest IT purchases they must make.

Remember that the US edition of ICD-10 is not the same as what's used elsewhere in the world. There is a base international standard, but multiple variants and additional codes layered on top of it -- with the version specified in the U.S. probably more complex because it's being used for billing rather than just statistical tracking.

This is where my liberal friends would point out how much simpler things would be in a single payer system.

Re: Convert and Train You Entire Staff in 90 Mins for $1,788 Annually (Mapping and Dual Coding) in Seconds

I hear a lot of this from EHR vendors, that ICD-10 shouldn't be a problem if only everyone would convert to their wonderful product. May even be some truth in it. Just got the cook's tour of Modernizing Medicine's iPad-based touch interface for recording patient encounters, which comes in custom editions for specialties like dermatology. Easy to see how working with a 3D model of the patient makes it possible to specify the correct region of the body without looking up a code. But you have to be in one of the specialties they cover for it to be helpful.

The emergency room doc I spoke with is worried about having to use multiple EHRs at different hospitals he contracts with. On October 1, doctors are going to be using all sorts of EHRs at different levels of capability related to ease of use and ICD-10. They're not all going to flock to your product or any other. Whenever this transition happens, it's going to bring pain and disruption -- the question is whether the time has come to get it over with.

Good points on both sides. As a facility medical coder, we have no idea what the small physician offices have to go through to make ends meet. I see your pain. On the other hand, why did the rest of the civilized world move to ICD10 in the 1990's? They somehow managed to make the transition well enough and Australia, for one, is in the 8th edition of ICD10 now. The US refuses to bite the bullet in all things fiscal and do what needs to be done and utilize all the modern technology we have available to us in the 21th century. I think that reimbursement would increase with the detail available in the new codes. I like the compromise the family doctor suggested a few posts ago and letting the large facilities move to ICD10 in 2014 and postponing it for the small offices to 2015.

cdavant3, I am a board member on a professional association for about 100 SOLO practitioners. I just sat down myself and went through the ICD-9 and the ICD-10 codes for conversions. For our profession the new codes are spectacular and very straightforward. The old ICD-9 codes really are inadequate and give the insurance companies more leeway to deny our claims. I for one regret the delay. I found one of those coding websites that only cost about $50 a month. It wasn't that hard to work with. I created superbills and a coding book for all our members. It was not rocket science.

Lewis, as a solo practitioner in a small field that is not well recognized by insurance companies I actually find the ICD-10s to make sense for my profession. They diagnoses are clear cut, unlike the ICD-9s which require all sorts of extra digits that make no sense whatsoever. I can't tell you how many practitioners in my profession have rejections thanks to the need to add the "fifth digit" codes for the ICD-9s.

Convert and Train You Entire Staff in 90 Mins for $1,788 Annually (Mapping and Dual Coding) in Seconds

The numbers being thrown around by, "The American Medical Association predicting this will be extremely costly for physicians, is false!!!!! "The AMA estimates the cost of switching to ICD-10 at as much as $8 million for a large physician practice and more than $225,000 for a smaller one". This is also grossly inflated.

What if I told you we have a solution that is cloud based and can covert the ICD-9 code to ICD-10 code in less than 2 seconds as well intelligently build your common codes automatically, in real-time with in a few seconds. And your staff can be trained with in 90 mins at a cost of $1,788 per provider annually or $149.00 per month. I demoed this to 3 well known health systems in Northeast, Ohio and the first comment I received was when can I get it and how much.

The government and the Big 5 Consulting firms are trying to scare all of these small practices and the large health systems in to thinking it will cost millions. That is a completely false. It will cost a small community health system in Ohio with 127 doctors in the network roughly $227,076.00 Annually ($1,788.00 avg., per provider), for all 127 practices. These are estimates, but based on what we where going to quote a small health system this is pretty accurate. I challenge anyone on this.

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